Friday, February 26, 2010

Stafford and the NHS

It is an old story, but it has been given new prominence by the Francis Report into what went on at the Stafford Hospital.

In a report by the Healthcare Commission last March, Sir Ian Kennedy, the commission's chairman, said, "There is no doubt that patients will have suffered and some of them will have died as a result. The investigation found there were too few doctors and nurses, vital equipment was not available when needed, patients did not receive the care they deserved and the trust had no system in place to spot when things were going wrong."

Among the most serious failings were filthy wards, with blood and excrement encrusted on surfaces; nurses with inadequate training were unable to operate cardiac monitors or intravenous pumps, which meant patients were not receiving the correct medication or the right dose of fluids.

Furthermore patients were "dumped" for hours and even days at a time in smaller units without a dedicated nurse to care for them. There were too few consultants in A&E to provide adequate cover and often there was no experienced surgeon in the hospital after 9pm.

Appalling standards of care put many patients at risk, and between 400 and 1,200 more people died than would have been expected in a three-year period from 2005 to 2008, the commission found.

The Commission stated: "An analysis of the trust's board meetings from April 2005 to 2008 found discussions were dominated by finance, target and achieving foundation trust status.

"There is little evidence that poor standards of nursing care were identified and discussed. The investigation found that poor results of surveys of patients or staff were not discussed in public. It found that a doubling of C. difficile infection in the early months of 2006 was not released to the board nor the public."

Inquiry chairman, Robert Francis QC, made 18 recommendations for both the trust and the government in his final report after hearing evidence from more than 900 patients and families. Mr Francis also identified a chronic shortage of staff, particularly nurses, as being largely responsible for the sub-standard care give to patients. He also said that while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion to patients.

Requests for assistance to use a bedpan or to get to and from the toilet were not responded to. "Patients were often left on commodes or in the toilet for far too long. They were also often left in sheets soiled with urine and feces for considerable periods of time, which was especially distressing for those whose incontinence was caused by Clostridium difficile. Considerable suffering, distress and embarrassment were caused to patients as a result. The inquiry also found that the attitude of some nurses "left much to be desired". It added: "Some families felt obliged or were left to take soiled sheets home to wash or to change beds when this should have been undertaken by the hospital and its staff. Some staff were dismissive of the needs of patients and their families."

It seems that the management of the hospital were more concerned with meeting government financial targets than caring for patients. Managers made nurses redundant to save money, but wasted over a million pounds in redundancy payments. At the same time they awarded themselves huge bonuses. The report can be viewed here.

How far should the disgraceful behavior at Stafford be seen as typical of the NHS? Is this what you get with 'socialized medicine'?

By definition this was not typical. Stafford was picked up because it was an outlier - by far the worst hospital in Britain. It is no more typical of the NHS than Harold Shipman was of GPs.

However, it does expose a risk when there is a monopoly provider in a particular area and the rigors of competition are removed. Where there is a state monopoly, institutions become too big to fail. Too big to fail is also a problem with other huge employers - take General Motors, Chryslers, and the Royal Bank of Scotland for example. To my mind it is a mistake to prop up failing enterprises. We must learn to manage failure. When a big company fails there will always be someone who can step in and buy what is valuable about the business - just as Barclays did with Lehman Bros. If there is a need for a service, a business will step in and fill it. When the British-owned car industry collapsed, the country didn't get out its bicycles; Nissan, Toyota and Honda stepped in and built factories. BMW, VW and Peugeot all stepped in and bought the profitable bits.

Although Stafford was the worst hospital in the NHS its problems were indicative of what can happen when government gets involved in healthcare. Because the taxpayer is footing the bill, there is a constant drive to cut down costs without concern for the individual circumstances of an area. Do you have more old people than normal? Your costs will be higher. Are house prices high in your area? You will have to pay more for adequate staff.

But we shouldn't lose sight of what is good about the NHS. Contrary to what people assume, there is a thriving insurance based system in the UK. But only 20% of the population chose to join it because the taxpayer-funded system is good enough for them. You might think it's because they don't want to pay twice, but in the US people pay twice: once in their taxes for Medicare, Medicaid, VA hospitals, the NIH, and County hospital ERs; and once for their insurance. And the proportion of the GDP spent on provided for government run services is much higher than the proportion of the (much smaller) British GDP spent on the NHS.

16 comments:

Anonymous
said...

Hi Dr. Hamblin...with all due respect to you I think comparing percentages of gdp is misleading without knowing how each country accounts for its expenditures...many for profit hospitals pay rent and taxes on their buildings and equipment in the U.S....is that part of the health care cost as reflected in your statement...does your health care system figure a rent factor???...I bring this up as I recently read a thesis by a canadian trying to compare the U.S. health industry with canadian health care and his conclusion seemed to be there were too many variables..the thesis mentioned some reasons why the U.S. system looked more expensive...things like the # of wars America has been involved in gives us many more veterans needing care...also the way canada accounts for capital improvements with some coming out of the general fund and some charged to the medical funding made comparisons highly subjective...GDP as an indicator of production or a nations wealth is also not reliable...example...in the 1960's cars built in the U.S. used almost exclusively american manufactured parts made with american labor and the sale of a car resulted in that value added to the GDP...when cars are assembled with parts from all over the world the resulting sale is still added to the GDP and yet the actual boost to the economy in this country is much less...maybe that is why we are having a jobless recovery according to our leaders...in summary the GDP # does not represent what it previously represented and comparing expenses is fruitless when the variables are so great...am curious that no British doctor involved at the facility in your blog did not blow the whistle and take pictures and call in the press as this incident seems pretty bad...is it true the british health care system is one of the worlds largest employers?...heard that in a debate and was unable to fact check it...one thing that always troubles me and that I have no answer for is that the amount of money spent by moral people on health care when millions are without clean water or are hungry...with limited dollars going forward should we be increasing funding for cll research or for childhood leukemia?...if you can comment on the Christian perspective I would be most apppreciative as this befuddles me....appreciate all you do and write about...romanbob

Despite America becoming increasingly indebted (especially to China) it has the largest economy and by far the greatest gross domestic product. The alarming 11% of GDP that the government spends on health includes tax breaks given to those purchasing health insurance. It excludes the cost of health care provided by medical insurance. Any taxes or rent to government would offset the amount paid by the taxpayer. For sure the government pays for those injured in war, but then so do the British and Canadian governments. As far as Afghanistan is concerned, both Canada and the UK have lost more troops per head of population than the USA.

It is wrong to think of the NHS as a single employer. It is not like the Red Army or the Indian Railway. Rather it is a conglomeration of small businesses with a single paymaster that is tightly regulated. Each GP practice comprises a group of doctors who contract with a purchaser to provide primary care to a given population. These doctors then provide the premises and staff to provide that care. There are rules on how many patients a practice can have on its books, and much of theincome comes on an item for service payment scheme - so much for a vaccination, so much for a cervical smear etc.

The money is given by the government to a ditrict purchaser on a weighted population basis (more if there are children or old people) This purchaser then contracts with general practices and with local hospitals to provide what is necessary. For example; they might buy 700 hernia repairs, 500 cholecytectomies 7 bone marrow transplants, 600 gastroscopies etc. In my ditrict there are two general hospitals and one provider of ultra specialist services (like cardiac valve surgery, neurosurgery and bone marrow transplantation) but they can shop around for these services if they can get them cheaper elsewhere - in London, for instance.

In Stafford there were whistleblowers among medical and nursing staff, but management was so deaf to complaints that there were no remedies. Others preferred to keep their heads down for fear of harming their careers.

You are so right about the anomalies in teh world. To make a real differenc eto mankind clean water in Africa would be a start. But even to get a nation to give 1% of its GDP in aid is a strugle.

Dr. Hamblin...thanks for your reply...was it correct to say the NHS then is one of the largest employers in the world with employer meaning they pay..regardless whether they are strictly an employee???...eg...if one works for the university system in calif they are paid by the state and federal government even tho they work for a school....also you mention death rates(being higher in some countries from the war then the U.S.)which from a dollar point of view deaths are probably cheaper for the individual country then a soldier that is wounded badly...eg..an old law school joke..if you hit someone and cause severe injury back up and run them over again as wrongful death damages are way cheaper then a lifetime of medical care...I do not believe in this view!!!...my comment on veterans naturally includes vietnam vets who are disabled not just the present war...and I did not even count the hundreds of thousands injured in auto accidents and the thousands injured by guns...problems that I believe your country does not have to the same extent...medical costs are a difficult issue to decipher...have a great weekend!!!...romanbob

"But only 20% of the population chose to join it [the private system] because the taxpayer-funded system is good enough for them."

Without knowing much of anything about life in the UK or ever even having been there, I would bet that this statement is essentially incorrect.

I would bet that the reason most do not join the private system is that they cannot afford it. And the reason they can't afford it is that people there are taxed to death and your nation is no where nearly as prosperous as it would be were it free rather than socialistic.

This being the case, they have no real "choice" but the soup your system gives them.

You can get private medical insurance for about the same cost as gym membership. People can afford it unless they are very poor, but they choose to spend their money on other things. Even people on benefits have color TVs, games machines and dishwashers and they choose to smoke cigarettes and drink alcohol. It's just a question of priority.

I agree that we are taxed too much, but most of our taxes go to bail out bankers.

With all due respect, I doubt most taxes are spent to bail out bankers.

On the subject of health care, it is stories that you cite that makes me greatly fear socialized medicine. And that is the aim of Obama and his far-left buddies.

I know that I receive excellent care for my aggressive CLL. I would not receive that care in Canada or the UK. I don't want to lose that excellent care.

On the subject of Stafford Hospital, you don't mention whether anyone is going to jail. The astonishing lack of care and the deliberate ignoring of patient's pleas are the worst kind of abuse I can think of. One goes to the hospital for rescue, not to be abused.

I hope and pray that they put the worst offenders in prison for a dozen or so years. That is the only thing that works for public employees, and people like Bernie Madoff.

I'm glad romanbob cites the studies he does. When I make similar argument, I am hooted down. The World Health Organization marks down the US ignoring the fact that the UK (for example) is far different. There are no Indian reservations in the UK that have no health facilities for 50 miles, as is the case in the Navajo lands. And the UK doesn't have 20 million illegal aliens who hide from the government, and use the ER as a health clinic.

One thing I find hilarious about BO's attempt to justify how we'll pay for the $3 trillion tab for BO care. He is counting on saving billions from Medicare fraud.

Well, what's stopping him from getting those savings now?

Oh, I get it! It's simple political posturing to fool the simpleton masses.

There will be a public enquiry about Stafford and people might well go to jail, although the size of the finacial crimes are dwarfed by Enron. Certainly some doctors and nurses are likely to lose their licenses to practise and some managers will be banned from working in the NHS.

Read Chonette's postings and you will see that she has excellent care for her aggressive CLL on the NHS. Read Chaya's site and you will find that PC had to come to England to get ofatumumab. But anecdotes are not evidence.

No, we do not have reservations for the indigenous populations of these islands; the Celts, Picts and Scots have integrated well into the British society, but we have had 2.5 million illegal immigrants from India, Pakistan, Iraq, Afghanistan, Somalia, Nigeria, Sierra Leone, Russia, Ukraine, Byelorus and the like in the past 10 years. I read that London schools have to deal with children speaking over 900 different languages. At least most of your illegals speak Spanish.

There are parts of Scotland and Cornwall that are very remote that need helicopters to take a doctor to them, although the problem is worse in Australia, while in the Sudan there are areas as big as Wales with only 4 doctors. We have friends who work in Malawi where it takes two weeks to reach a doctor because the villagers have neither transport nor radio.

I have no wish to inflict the NHS on the US. I just wish that those who oppose BO's plans would not cherry-pick rare disasters like Stafford as exemplars of the general quality of the NHS. My hospital was clean, effeicient, innovative, caring and effective. From it emerged what has proved to be the major new understanding of CLL in the past decade. Stafford was exposed because it was an outlier. That means it was not typical; just as Dr Shipman was not typical of all GPs or Dr Crippen typical of all dentists.

America must find its own solutions, but it should not deny it has a problem. It has pockets of extreme excellence surrounded by areas of squallor. It is also extremely expensive. It can rightly say that it subsidises the rest of the world by paying top prices for new drugs, but then many of those new drugs emerge from Universities in Britain, Germany, France and Switzerland (for example: monoclonal antibodies were invented by an Argentinian who took British nationality at the time of the Generals and a German who were both working at a British University). The Drug Companies post a return on investment higher than in almost any other industry. Their shareholders are to a large degree American. Some Americans ripping off other Americans.

I agree that all our taxes don't go to pay bankers, but the British taxpayer is in debt to the tune of $300 billion dollars because of the measures it took to protect the banks from failure. When I see bankers picking up $5 million bonuses it jars.

Hi Dr. Hamblin...just want it known I am not in any way trying to "win" any argument just advance the debate...America does not really have a health care problem if that is to mean people not getting care...we largely have a spending problem...we could pay for all the uninsured simply by running a balanced budget and using the over 400 billion in interest we pay to pay for the uninsured. Other savings can be obtained if we quit backstopping the rest of the world..I am not an isolationist but...by having bases throughout Europe this has allowed much of Europe to spend on social programs while we pick up europes spending on defense...our presence, our men, our equipment, our taxes...how many europeans are stationed in America?...how many british bases are there throughout the world...last I checked we had a military presence in over 120 countries. Obama is correct when he says other countries should shoulder more of the load...but I forgot...they pay for their own citizens medical care and cushy retirements and do not have money for defense....obviously a free europe is in americas best interest but at what cost to our own social spending?...As an investor in Pfizer I can honestly say that since about the year 2000 the stock has done nothing...after reinvesting all dividends(must add I pay income taxes on those dividends after pfizer pays corporate tax on the profits..double taxation) that the value of the stock I own is now less then it was then...and I have approximately 600 more shares of stock!!!)...where is the ripoff..of me?..or are retirement funds throughout our country being ripped off who invested in pfizer counting on a good return who now are getting less return and negative stock price appreciation and therefore having to raise taxes to cover public retirement accounts with us in the private sector falling into a deeper hole...how much money was made in london or new york for that matter, when banking houses set up and governments taxed them to spend the money on social services instead of regulation...It seems in so many ways government is the problem and tho necessary must be limited...off the soapbox...still confused how a Christian should react to health care for all and in a democracy wondering if we should be limiting what Caeser takes and doing our own charity...you wrote a good piece on that a while back...thanks Dr. Hamblin...romanbob

There are lots of countries in the world who wish that America would remove their bases. America has bases in the UK for America's interests not ours. Bases in Germany are no longer for Germany's interest. I don't believe there are any in France.

Britain still has bases in many countries (Belize, the Falklands, Deo Garcia - no I forgot that has been loaned to the Americans for zero rent) and when it took on the role of the world's policeman it had many more. Nobody asked America to police the world. It is entirely in its own interest that it does so. Don't complain about the cost. Bring your troops home.

I'm not interested in stocks and shares, but I understand that Pharmaceutical companies do not pay big dividends but they do operate in other shareholder friendly ways. They certainly make huge profits, largely out of American health insurance companies.

As I said whether America has a healthcare problem is for Americans to decide. Just don't cherrypick incidents in the UK NHS to deride a taxpayer funded system. I'm pretty sure that I could find incidents in America which would make your system look bad, but anecdotes aren't evidence. Despite the problems most people in the UK are very satisfied with what they have.

Is it a Christian thing to have a taxpayer funded system? I don't think so. There are many ways of funding health care. Germany and France both have insurance based systems very similar to America's. It is a Christian thing to show kindness to people and to care for widows and orphans, but is also a Christian responsibility to provide for one's own family. It is also a Christian precept that those who will not work should not eat. Mind you, that is 'will not' not 'cannot'.

Wow Dr. Hamblin...agreement on many things...I think most Americans would agree we should not be the worlds policeman and that we can better spend the money at home...not sure how poland might think about that tho...but I recognize they are only one country...am a bit surprised you do not care about stocks and shares as their growth is how pensions are paid...both private and public...we in california are facing a public pension shortfall equal to the total of one whole years budget...much of that money is invested in stocks and bonds in markets throughout the world...some things are unsustainable...hope and pray that your government continues to be able to raise taxes to pay for your pension...or invests the money to get a gain to pay it...your comment in this matter reminds me of a blog you wrote about experts being experts in one area but not another...in matters of morality and Christian understanding I believe your commentaries would put many church leaders to shame...off topic...I recently found some mysteries titles Foyles war about a british investigator who cannot join the military but continues his job of investigating murders and graft and corruption during world war two...was curious if you had an opinion on them...I enjoy the fact you do not use ancedotal evidence as then it becomes a matter of adding up a score as to who made the better points as opposed to the principals, like personal responsibility, that should be looked at in many issues...have a great day Dr. Hamblin...with repect...romanbob

We agree. Of course America acts in its own interest. So should we all.

Romanbob

I have no understanding of finance - I have never studied it and have better things to do with my time. I know that if I didn't have my pension I could earn a lot of money as a physician, but I have enough to live on and to spare.

Foyles War was a TV series in Britain, which I very much enjoyed. The show was cancelled rather abruptly, but I gather it has been reinstated and will film again this summer.

Foyle's War was indeed very good. However, it didn't end abruptly. The last one or two episodes coincided with the end of the war. The pretty military woman left the service and Foyle rode off into the sunset (figuratively).

Unless they go back in time, with a Foyle older than when he retired at the end of WWII, perhaps they will have to have Foyle in a walker when he fights crime in the Gulf War.

As for American health care not having a problem, here is what someone posted today on one of the CLL discussion sites:Here are some expenses you may be responsible for, even with insurance: . Drugs that aren't on your formulary or that cost more than your usual prescriptions. High deductible costs. Out-of-network cancer care costs, which usually have a different deductible that must be met. Any pre-existing condition limitations on your treatment. Any treatments or procedures not covered by your plan. Any costs that exceed your lifetime maximum, if your cancer treatment is ongoing and very expensive

I'm not sure what to make of your last post. Surely you applaud Americans paying a lot out of pocket for our 'Cadillac' health care system.

Getting cancer is expensive. That I pay a lot of money out-of-pocket is understandable, isn't it? I get excellent care and I expect to pay for it (some of it, at least).

I don't think you can refute the fact that the NHS won't pay for many cancer drugs that are life-saving drugs. It took over 12 years to get rituximab to be approved in the UK.

I spoke to a nephrologist one time and he said the drugs that NICE wouldn't approve 'revolutionized' his practice.

As for the cost of drugs, Medicare won't negotiate with American drug makers. I doubt it even negotiates with foreign drug makers.

I think one of your 'touchy' points that you have mentioned repeatedly is the fact that some drugs are invented outside of the US. Who ever denied that? Apart from the fact that Americans are fantastic people and America is a fantastic country, we are honest enough to admit that we haven't invented everything worthwhile in the pharmaceutical industry.

We all know that Campath was developed in Cambridge, if memory is correct.

As far as a Cadillac health service is concerned: fine. Those who can afford it pay for it. What is often not realised is that in the UK there is a Rolls-Royce service available that moderately well-off to rich people can have. Companies like BUPA, PPP, Norwich Union etc make this Rolls-Royce service available to about 20% of the population, often as part of their employment package.

But that is not the whole story. In the UK, everyone, including the illegal immigrant, is covered by a 'Ford or GM' service which entitles them to a personal physician, vaccinations, pregnancy cover, screening for serious disease, ambulances, elective surgery, basic dental care, care for chronic illness and emergency care. The only limit on this is that if a particular treatment cost more than $50,000 to produce an extra year of high quality life, then they must find a way of paying for it themself either by an insurance policy or out of their own pocket.

There are some added costs that are less well known. Each prescription costs $10, though you can buy a 'season ticket' to cover all your prescriptions for a year for $150. Major dental work has to be paid for, either by insurance or out of your own pocket. Eye tests cost $15 and you have to buy your own spectacles.

All this costs the taxpayer 7.5% of GDP. The back-up to the insurance system in America costs 11% of GDP.

Some people elect to buy their own health insurance, but an insurance salesman told me it was a poor buy. Better, he said, to invest the same amount of money elsewhere and use that investment to supplement what the NHS provides if the need arises. I have done this a couple of times and reckon that I am running at a profit.

If you want to see your own family doctor for anything other than an emergency you may have to wait a week, though you will always be able to see one of his partners the same day. If you need to see a specialist then, if cancer is suspected, you must be given an appointment in fewer than 14 days. Otherwise, it may be a little longer. However, if you have a couple of hundred dollars you can see him the same week. Elective non-cancer surgery can involve a wait - anything from 6 to 18 weeks, but again if you pay you can circumvent the wait. Having insurance cover means that you can buy a private room, rather than being in a ward with 5 other people. You may also get a better standard of food and more TV channels.

It wasn't just Campath that was developed in Cambridge. The concept of monoclonal antibodies was produced there. They won the Nobel prize and then gave the technology to the world without patenting it. It would have been more justy to patent it and license it for free, since an American company was able to get a patent for the obvious application of the technology. Gene sequencing was also developed at Cambridge and from this have come all the imatinib-like drugs that we currntly enjoy.

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Born in Worcester, England 1943; school at Farnborough, Hampshire 1954-62; University 1962-7 and junior doctor posts 1967-74 in Bristol; Consultant Haematologist Bournemouth 1974-2003; Professor of Immunohaematology Southampton 1986 to present. Honorary Consultant Haematologist Kings College Hospital, London, 2004-present. After 5 years of working part time researching, writing, reviewing, editing, speaking, sitting on committees, advising, answering questions and thinking, I now think of myself as fully retired apart from my role as Editor in Chief of the medical journal Leukemia Research. I was awarded the Binet-Rai medal for outstanding research in CLL in 2002 and this has been my most sucessful area of research, but I have also made important contributions in the fields of apheresis, stem cell transplantation, myeloma, myelodysplastic syndrome, antibody therapy, cytokine therapy and DNA vaccines. I was once mascot for Aldershot Town Football. Club. Married to Diane for 44 years. Four children, Karen, Richard, Angela and David.